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2. Date Gas Required*
   Date Gas Required
3. Date of Request*
   Date of Request
5. Name of Applicant*
6. Phone*
8. Service Address*
9. Email*
11. Person to Contact*
13. Type of Equipment to be Installed

    1. Gas Furnace
    2. Water Heater
    3. Range
    4. Dryer
    5. Vented Fireplace
    6. Unvented Fireplace Logs
14. When requesting information from Natural Gas of Milton, rest assured we have appropriate security measures in place to protect against the misuse of information we have collected from you.
    
    Thank You!
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16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

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